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Pennsylvania Free Printable Health Insurance Coverage Information Request (REV-1882) for 2024 Pennsylvania Health Insurance Coverage Information Request

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Health Insurance Coverage Information Request
Health Insurance Coverage Information Request (REV-1882)

2110010051 (EX) MOD 07-21 (FI) REV-1882 HEALTH INSURANCE COVERAGE INFORMATION REQUEST Name shown first on the PA-40 (if filing jointly) START ➜ 20 Social Security Number PURPOSE: The purpose of the REV-1882, Health Insurance Coverage Information Request, is to connect uninsured Pennsylvanians with information regarding their eligibility to enroll in health insurance coverage through the Pennsylvania Health Insurance Exchange Authority, also known as Pennie™. Pennie is Pennsylvania’s health insurance marketplace. The Pennsylvania Department of Revenue and Pennie have teamed up to gather information from residents who do not have health insurance coverage, making it easier to apply and enroll in comprehensive health insurance through Pennie. By answering the questions below, you are giving permission for the Pennsylvania Department of Revenue to share information from your state tax return (such as your household size and income) with Pennie so that Pennie can evaluate your eligibility for no-cost or low-cost health care coverage. Email Address Telephone Number 1. Select oval if you do not have health insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 2. Select oval if your spouse (if married, filing jointly) does not have health insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 3. Select oval if any dependents included on your federal tax return do not have health insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Select oval if you consent to allow Pennie to communicate with you via telephone or email . . . . 4. 5. Please provide your adjusted gross income from Line 11 of your federal tax return . . . . . . . . . . 5. s s 00 l 6. Please provide the number of household members included on your federal tax return . . . . . . . 6. 7. Please provide the date of birth for yourself, your spouse (if married, filing jointly), and all tax dependents under age 26 within your household who do not have health insurance coverage. Taxpayer Date of Birth (MM/DD/YYYY) Spouse Date of Birth (if married, filing jointly) (MM/DD/YYYY) Dependent(s) Date(s) of Birth (MM/DD/YYYY) 2110010051 Reset Entire Form 2110010051 NEXT PAGE PRINT Instructions for REV-1882 REV-1882 IN (EX) 07-21 GENERAL INFORMATION The Pennsylvania Health Insurance Exchange Authority, also known as Pennie™, is Pennsylvania’s state-based health insurance marketplace providing Pennsylvanians with access to affordable health insurance. Pennie has partnered with the Pennsylvania Department of Revenue to establish a program whereby Pennsylvanians can provide eligibility information to Pennie while filing their Pennsylvania Income Tax return. PURPOSE OF FORM The purpose of the REV-1882, Health Insurance Coverage Information Request, is to provide uninsured Pennsylvanians with a way to submit information to Pennie. Pennie will use this information to assist you in determining your eligibility for enrollment in health insurance with financial assistance. For additional information regarding Pennie, please visit www.pennie.com. If you are uninsured and want to understand your eligibility for health insurance through Pennie, you can complete this form. By completing this form and attaching it to your signed Pennsylvania Personal Income Tax Return, you authorize the Department of Revenue to supply tax information from your return (including your name, address and Social Security number) and the information provided on this form to Pennie. NOTE: Executing this form is completely voluntary. You are not required to fill out this form to file your Pennsylvania Personal Income Tax Return. FORM INSTRUCTIONS Provide the primary name, primary SSN, email address and telephone number where indicated. www.revenue.pa.gov RETURN TO PAGE 1 Health Insurance Coverage Information Request LINE INSTRUCTIONS LINE 1 Fill in the oval if the primary taxpayer does not have health insurance coverage. LINE 2 Fill in the oval if the primary taxpayer’s spouse (if married filing jointly) does not have health insurance coverage. LINE 3 Fill in the oval if any dependents included on your federal tax return do not have health insurance coverage. LINE 4 Fill in the oval if you consent to allow Pennie to communicate with you via telephone or email. LINE 5 Provide your adjusted gross income from Line 11 of your federal tax return. LINE 6 Provide the number of household members included on your federal tax return. LINE 7 Provide the name and date of birth (MMDDYYYY) for the primary taxpayer, and the primary taxpayer’s spouse (if married filing jointly). Provide the date of birth (MMDDYYYY) of the dependent(s) (from Line 3) within your household who are under age 26 and who do not have health insurance coverage. REV-1882 1
Extracted from PDF file 2023-pennsylvania-form-rev-1882.pdf, last modified October 2021

More about the Pennsylvania Form REV-1882 Individual Income Tax TY 2023

: The purpose of the REV-1882, Health Insurance Coverage Information Request, is to connect uninsured Pennsylvanians with information regarding their eligibility to enroll in health insurance coverage through the Pennsylvania Health Insurance Exchange Authority, also known as Pennie.

We last updated the Health Insurance Coverage Information Request in February 2024, so this is the latest version of Form REV-1882, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form REV-1882 directly from TaxFormFinder. You can print other Pennsylvania tax forms here.

Other Pennsylvania Individual Income Tax Forms:

TaxFormFinder has an additional 174 Pennsylvania income tax forms that you may need, plus all federal income tax forms.

Form Code Form Name
Form PA-40 Pennsylvania Income Tax Return
Form 40 Instruction Booklet Income Tax Return Instruction Booklet (PA-40)
Form PA-40 SP PA Schedule SP - Special Tax Forgiveness
Form PA-40 A PA Schedule A - Interest Income
Form PA-40 PA-V PA-40 Payment Voucher

Download all PA tax forms View all 175 Pennsylvania Income Tax Forms


Form Sources:

Pennsylvania usually releases forms for the current tax year between January and April. We last updated Pennsylvania Form REV-1882 from the Department of Revenue in February 2024.

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About the Individual Income Tax

The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.

Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!

Historical Past-Year Versions of Pennsylvania Form REV-1882

We have a total of three past-year versions of Form REV-1882 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2023 Form REV-1882

Health Insurance Coverage Information Request (REV-1882)

2022 Form REV-1882

Health Insurance Coverage Information Request (REV-1882)

2021 Form REV-1882

Health Insurance Coverage Information Request (REV-1882)


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